TeenScreen Primary Care
Guide to Coding and PaymentTeenScreen® Primary Care
TeenScreen® Primary Care
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Contents1 Overview......................................................................................................................................................2
2 Preventive Medicine Visit Codes...........................................................................................................3
3 Screening and Assessment Codes......................................................................................................3
4 Evaluation & Management Codes and the Mental Health Visit.........................................................3
5 Modifiers...............................................................................................................................................4
6 Non Face-to-Face Services.......................................................................................................................5
7 Substance Use Screening Codes..........................................................................................................5
8 Consultation Codes.............................................................................................................................5
9 Other Relevant Codes..........................................................................................................................5
10 ICD-9 Codes.........................................................................................................................................6
11 Federal Policy Changes Will Expand Access to Mental Health Screening and Follow-Up Services..6
12 Appendix A – Sample Coding Sheet to Share with Billing Staff............................................................7
13 Appendix B – List of Resources and References...............................................................................8
14 Appendix C – Comprehensive List of Relevant ICD-9 Codes............................................................9
OverviewThis Guide Coding and Payment is designed to give primary care providers (PCPs) helpful information about coding and obtaining payment for screening and addressing/ managing mental health in the primary care office. It includes relevant codes that may be used to bill for time spent addressing mental health with adolescent patients. It also provides suggestions for combinations of codes that can be used when offering mental health screening during routine office visits. Please note that this information is designed to provide helpful tips for obtaining payment through a number of insurance carriers, but that these codes are not guaranteed to work with all payers.
It is recommended that PCPs consult with their office’s coding and billing staff to determine the combination of codes that will work best for screening and providing mental health services. It is also suggested that the billing office reach out to the health plans the provider participates in to inquire about whether they provide payment for mental health screening and, if so, to clarify with the health plans what coding procedures should be followed. The information provided in this section can be shared with health plans to see if they accept the codes in this guide.
TeenScreen and American Academy of Pediatrics Webinar Series
The TeenScreen National Center has partnered with the American Academy of Pediatrics to offer a series of webinars on addressing mental health in primary care. The topics of the webinars vary however many touch on coding and payment for addressing and managing the mental health of adolescent patients. Some of the information in this guide is compiled from expert guidance and testimony presented during selected webinars (see below). For more information, please visit the
“Resources” section of this guide in the Appendix.
Featured Webinars:
On the Front Line: How Pediatricians Can Improve Teen Mental Health
November 30, 2010
http://www.teenscreen.org/library/events-webinars/on-the-front-line-how-pediatricians-can-improve-teen-mental-health
Priorities and Practicalities: Obtaining Payment for Mental Health Services In the Pediatric Office
January 27, 2011
http://www.teenscreen.org/library/events-webinars/making-adolescent-mental-health-a-priority-payment
Featured Expert Speakers:
Jane Meschan Foy, MD, FAAP, professor of pediatrics and coordinator of the Integrated Primary Care Mental Health
(MH) Program for the Northwest Area Health Education Center at Wake Forest University School of Medicine.
Kelly J. Kelleher, MD, MPH, Director of the Center for Innovation in Pediatric Practice at the Research Institute
at Nationwide Children’s Hospital and Professor, Department of Pediatrics, The Ohio State University College of
Medicine.
Lynn M. Wegner, MD, Associate Professor of Pediatrics, Developmental and Behavioral Pediatrics, the University of
North Carolina, Chapel Hill.
Thomas K. McInerny, MD, Associate Chair for Clinical Affairs and Professor of Pediatrics, University of
RochesterMedical Center/Golisano Children’s Hospital at Strong.
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Codes Relevant to Addressing Mental Health in Primary Care
Mental health assessments and discussions about mental health with patients and families can be time and resource intensive. Below are a number of codes that may be used to bill for mental health related issues:
Preventive Medicine Service Codes
These codes are typically used for annual well-child visits and may be
used in combination with other codes for mental health screening.
Screening and Assessment Codes
The following are codes that are relevant to screening and
assessment:
96110: Standardized, Developmental Testing/ Screening; limited
with interpretation and report
96110 is an appropriate code to use for routine mental health/
depression screening offered to adolescent patients. This code
is often reported when performed in the context of preventative
medicine services, but may also be reported when screening is
performed with other evaluation and management (E/M) services.
When a limited screening test is performed along with any E/M
service, both services should be reported and a modifier 25 should be
appended to the E/M code (see E/M section below).
When using 96110, the expectation is that the screening
tools will be completed by a non-physician staff member and
reviewed by the physician; meant to cover the practice costs
only (and not physician time).
96110 can be reported in addition to E/M services provided on
the same data with a modifier.
Medicaid may not pay for multiple units of 96110.
At this time, 96110 is the only CPT code available for the non-
interactive screening and rating scales used for mental health
care
Use one unit of 96110 for each individual screening
questionnaire or rating scale administered, scored and
interpreted.
96111: Standardized, Developmental Testing/ Screening
This code is used when developmental testing is extended with
interpretation and report. This code is most often used when
screening/ testing younger patients for developmental disorders.
99420: Health Risk Assessment
May be used for the administration and interpretation of a health risk
assessment instrument.
96116: Neurobehavioral status examination
96120: Neuropsychological testing
By computer with qualified health care professional interpretation and
report.
Evaluation and Management (E/M) Codes and Mental Health Visits
Bill based on level of complexity – history, physical exam
(PE), medical decision making (MDM). Clues to higher levels of
decision making: high-risk for morbidity (e.g., autism, bipolar,
depression, etc), laboratory or other diagnostic tests requiring
review, extensive differential diagnosis.
Bill based on time – only if counseling and coordination of care
> 50% of visit.
Counseling and Care Coordination
Initial assessment involves time to determine the differential
diagnosis and potential treatment options. When counseling and/ or
coordination of care accounts for more than 50% of the physician-
patient and/ or family encounter, time may be considered the
controlling factor to qualify for a particular level of E/M service (note –
this does not include screening time; screening is reported separately
with a modifier). In these cases, the three key components of history,
PE and MDM may be ignored (only time is used to select the level of
care).
Clinicians must keep careful records of the total time spent with
the patient and the amount of that time spent in counseling or care
coordination, as well as a summary of issues discussed. Proper
documentation of the visit is critical to justifying the use of E/M
codes.
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New Patients
99383 (5–11 years old)
99384 (12–17 years old)
99385 (18+)
Established Patients
99393 (5–11 years old)
99394 (12–17 years old)
99395 (18+)
New Patients Established Patients
99201 (10 minutes) (level 1 complexity) 99211 (5 minutes)
99202 (20 minutes) (level 2 complexity) 99212 (10 minutes)
99203 (30 minutes) (level 3 complexity) 99213 (15 minutes)
99204 (45 minutes) (level 4 complexity) 99214 (25 minutes)
99205 (60 minutes) (level 5 complexity) 99215 (40 minutes)
How to Code for Counseling and Care Coordination:
May be used when the patient is present or when counseling a
parent when the patient is not physically present
Document the discussion‘s topic
When time spent in counseling and/or care coordination is over
50% of face-to-face time, CPT says you shall use this as the
critical factor to qualify for a particular E/M service level
Pediatrician spends the majority of parent-only conference on
counseling→ code based on time
Time-based coding also may be used for follow-up appointments
to discuss management of common medication side-effects
such as appetite and/or sleep changes, behaviors requiring
environmental changes rather than medication adjustment
Documentation Requirements to Bill Based on Time
The total length of time of the encounter should be documented
and the record should describe the counseling and/or activities
to coordinate care
The medical record must reflect the extent of counseling and/or
coordination of care
Resident/NP/PA face-to-face time cannot be included (except
under specialty specific Medicaid contracts)
It is a good idea to note in a separate paragraph what
documentation is supporting the counseling/coordination of
care; this will make it easy to justify the time spent
Example:
Physician spends 25 minutes face-to-face with an established
patient: 15 of those minutes are spent in counseling or care
coordination. 25 minutes is the typical duration of code 99214.
Because more than 50% of that time was spent in counseling or
care coordination, the clinician could use 99214 regardless of the
history, physical examination, or medical decision-making provided
during that encounter.
Modifiers
Modifiers are a two-digit suffix that are appended to a CPT code;
when using modifiers, the medical record must support their use.
Not all modifiers are recognized by all payers.
Modifier 25Modifier 25 tells insurers that the particular visit is different; it should
be added to the office/ outpatient visit to indicate that a significant,
separately identifiable E/M service was performed in addition to
the preventive medicine visit. The additional work above and beyond
the work of the preventive medicine visit should be reflected in the
additional E/M code.
Modifier 76Repeat procedure or service by the same physician or other qualified
health professional subsequent to the original procedure or service.
This modifier is appended to the procedure, not the E/M service.
It tells the payer that this is not a duplicate service. The repeat
procedure may be performed on different days.
Modifier 59Modifier 59 can be used to identify distinct and independent
procedures that are not normally performed together but do occur
appropriately on the same date of service. It indicates the procedure
was distinct from the other procedures performed on that same date
of service. Only use Modifier 59 if it best explains the circumstances
and no other, more descriptive modifier is available (Modifier 59 is
the modifier of “last resort,” according to the American Academy of
Pediatrics Coding for Pediatrics Manual). Do not append modifier 59
to an E/M code and do not use in place of modifier 25.
Slide taken from “Priorities and Practicalities: Obtaining Payment for Mental Health Services in the Pediatric Office,” presented January 27, 2011.
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Using 96110 with E/M and Modifier
Use one unit for each individual screening questionnaire or rating
scale administered, scored and interpreted.
If mother, regular teacher and special ed teacher each completed
Vanderbilt Scales, then 3 x 96110.
Append modifier -25 to E/M to show the E/M is a separate and
identifiable service by the same physician (on the same day of
the procedure) from the procedure performed (e.g., 99215-25,
96110).
Alternatively, if the payer does not permit modifier -25: Append
modifier -59 (distinct procedural service) to 96110 to show the
services were separate and necessary at the same visit.
Non Face-to-Face Services
Telephone Care
9944x: Telephone E/M service provided by a physician to an
established patient, parent or guardian not originating from a related
E/M service provided within the previous 7 days nor leading to an E/M
service or procedure within the next 24 hours or soonest available
appt.
99441: 5-10 min. medical discussion
99442: 11-20 min. medical discussion
99443: 21-30 min. medical discussion
• Telephone care levels may represent three levels of complexity
– need to document this to support charge.
• Documentation should:
Be thorough
Fulfill the need for continuity of care
Describe the complexity of the call
Meet the requirements of the typical E/M visit
A general note including the key elements of history and
medical decision-making
Time spent on call
Care Plan Oversight
Recurrent physician supervision of a complex patient or patient who
requires multidisciplinary care and ongoing physician involvement.
99339: 15-29 minutes/month
99340: Greater than 30 minutes/month
• Non face-to-face
• Reflect the complexity and time required to supervise the care
of the patient
• Reported separately from E/M services
• Reported by the MD who has the supervisory role in the
patient’s care or is the sole provider
• Reported based on the amount of time spent/calendar month
• Services less than 15 minutes reported for the month should
not be billed
Services Might Include:
• Regular physician development and/or revision of care plans
• Review of subsequent reports of patient status
• Review of related laboratory and other studies
• Communication (including telephone care) for purposes of
assessment or care decisions w/ healthcare professionals,
family members, legal guardians or caregivers involved in
patient care
• Integration of new information into the medical treatment plan
and/or adjustment of medical treatment
• Attendance at team conferences/meetings
Team Conferences
99367: Medical Team Conference w/ interdisciplinary team of
healthcare professionals
• Participation by physician
• Patient and/or family NOT present
• If patient/family present, report attendance w/ appropriate
E/M service based on time
• ≥ 30 minutes
• If you include attendance at a meeting as part of the time on
home care plan oversight, do not submit a separate bill.
Substance Use Screening Codes
99408 – Alcohol or substance (other than tobacco) abuse -
structured screening and brief intervention (SBI) services; 15 to 30
minutes.
99409 – Alcohol or substance (other than tobacco) abuse structured
screening brief intervention services; greater than 30 minutes.
Consultation Codes
99241-99245 – the key components that must be present to use
consultation codes are as follows:
• REQUEST for consultation is made and documented in the
chart.
• Consulting clinician RENDERS an opinion or advice back to the
requesting source.
• Consulting clinician provides a written REPORT back to the
requesting source.
• Source of request examples: school personnel, another
colleague in the same practice, a therapist, a nurse
practitioner, an attorney
• 3 key components—history, physical examination, and medical
decision-making—must be performed and documented.
Other Relevant Codes
S0302 – Completed Early and Periodic Screening, Diagnostic, and
Treatment (EPSDT) service (List in addition to code for appropriate
E/M service).
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Relevant ICD-9 (Diagnosis) Codes – Understanding Diagnostic Coding
• ICD-9 codes must be the most specific
• ICD-9 codes selected as the #1 diagnosis must describe in detail
the condition necessitating the visit
• The diagnosis code does not determine the level of E/M service
• V-codes are usually accepted as a secondary diagnosis but can
be problematic as the primary diagnosis
→799.9 – other, unknown and unspecified cause
(undiagnosed disease, not specified as to site or system
involved; unknown cause of morbidity or mortality)
→V20.2 – well-child, preventative health visits →V79.8 – special screening exam for mental disorders and
developmental handicaps →V40.0 – mental and behavioral health problems
See Appendix C for a comprehensive list of ICD-9 codes related to mental health conditions, co-morbid conditions, etc.
Federal Policy Changes Will Expand Access to Mental Health Screening and Follow-Up Services
Beginning this year, the Mental Health Parity and Addiction Equity
Act (MHPAEA) of 2008 will significantly expand access to mental
health and substance abuse services. MPHAEA requires that large
group health plans offering coverage for mental health and substance
abuse services to do so in a way that creates an equal footing with
medical/surgical coverage. In other words, the traditionally more
restrictive limitations on coverage for mental health and substance
abuse services are no longer permitted. This applies to both financial
requirements, i.e., co-pays and deductibles, as well as to treatment
limitations, such as visit limits or medical management techniques.
MHPAEA protections went into effect in 2009. However, regulations
detailing how to comply with the law were not released until 2010
and did not go into effect for most plans until the start of the new
plan year on January 1, 2011. Enhanced access to mental health and
substance abuse services can be expected now that the regulations
are in force.
Signed into law on March 23, 2010, the Affordable Care Act (ACA)
has expanded access to health coverage and extended numerous,
new consumer protections. Several provisions will specifically
address access to mental health screening and necessary follow-up
services. For example, the ACA requires that all new health plans
offer a recommended set of preventive services to beneficiaries
without cost-sharing. These free preventive services must include all
screenings recommended by the U.S. Preventive Services Task Force,
including adolescent depression screening. Health care reform also
established mental health services as an essential benefit for new
health plans and extended federal mental health parity protections to
new types of plans. Taken together, these provisions will significantly
expand access to mental health screening and services.
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Appendix A Sample Coding Sheet to Share with Billing Staff
Type of Visit CPT Codes for Well-Child Visit
E/M Codes Based on Time
Modifier ICD-9 Codes Developmental Screening
Code
Annual Well-Child Exam with Mental Health
Screening
99393 5-11 est. patient 99211 5 minutes; est. patient
25
V20.2 – well-child/ preventative health visits
V79.8 – special screening exam for mental disorders and developmental handicaps (negative screening)
V40.0 – mental and behavioral health problems (positive screening)
96110
99394 12-17 est. patient 99212 10 minutes; est. patient
99395 18+ est. patient 99213 15 minutes; est. patient
99383 5-11 new patient 99214 25 minutes; est. patient
99385 18+ new patient 99215 40 minutes; est. patient
99201 10 minutes; new patient
99202 20 minutes; new patient
99203 30 minutes; new patient
99204 45 minutes; new patient
99205 60 minutes; new patient
These well-child codes may be used in conjunction with codes for mental health screening
Can be used if counseling and care coordination > 50% of the office visit time
Modifier 25 should append the E/M Codes and not the developmental screening code
Type of Visit CPT Codes(E/M Codes Based on Time)
Modifier ICD-9 Codes Developmental Screening
Code
Routine Office Visit with
Mental Health Screening
99211 5 minutes; est. patient
25
V79.8 – special screening exam for mental disorders and developmental handicaps (negative screening)
V40.0 – mental and behavioral health problems (positive screening)
96110
99212 10 minutes; est. patient
99213 15 minutes; est. patient
99214 25 minutes; est. patient
99215 40 minutes; est. patient
99201 10 minutes; new patient
99202 20 minutes; new patient
99203 30 minutes; new patient
99204 45 minutes; new patient
99205 60 minutes; new patient
Can be used if counseling and care coordination > 50% of the office visit time
Modifier 25 should append the E/M Codes and not the developmental screening code.
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Appendix B Resources and References
American Academy of Pediatrics (AAP) Coding Hotline
AAP Coding Fact Sheets for Primary Care Clinicians –Available on AAP Member Center
• Developmental Screening and Testing
• Anxiety
• Bereavement
• Depression
• Inattention, Impulsivity, Disruptive Behavior, and Aggression
• Post-traumatic Stress Disorder
• Substance Use/Abuse
• 2010 AAP Coding Fact Sheet for Pediatric Preventive Care - http://brightfutures.aap.org/pdfs/Preventive%20Care%20Coding%20Manual%202010.pdf
State AAP Chapters – many can offer assistance with local coding procedures and practices
• http://www.aap.org/member/chapters/chaplist.cfm
Commercial Pediatric Coding Newsletters
• American Academy of Pediatrics, Pediatric Coding Companion
• The Coding Institute. Pediatric Coding Alert.
Web Sites
• Web site of the AAP section on Developmental and Behavioral Pediatrics with coding information specific to developmental and behavioral care for childre - www.dbpeds.org
• Web site of the American Academy of Child and Adolescent Psychiatry with coding information - www.aacap.org
• Includes links to the different webinars hosted by the TeenScreen National Center, including those co-sponsored by the American Academy of Pediatrics - http://www.teenscreen.org/library/events-webinars
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Appendix C Comprehensive List of Relevant ICD-9 CodesCross Walking Diagnostic Codes: Attention Deficit/Hyperactivity Disorder (DSM)
• 301.11 Chronic hypomanic personality disorder• 310 Specific nonpsychotic mental disorders due to brain damage• 310.0 Frontal lobe syndrome• 310.2 Postconcussion syndrome• 310.8 Other specified nonpsychotic mental disorders following organic brain damage• 310.9 Unspecified nonpsychotic mental disorders following organic brain damage• 314 Hyperkinetic disorder of childhood• 314.0 Attention deficit disorder• 314.00 W/out mention of hyperactivity• 314.01 W/ hyperactivity• 314.1 Hyperkinesis w/developmental delay• 314.2 Hyperkinetic conduct disorder• 314.8 Other specified manifestation of hyperkinetic syndrome• Unspecified hyperkinetic syndrome • 331.83 Mild cognitive impairment, so stated• 348.3 Encephalopathy, NEC• 760.71 Fetal alcohol effects (FAS)• 783.42 Delayed milestones• 799.21 Nervousness• 799.22 Irritability• 799.23 Impulsiveness• 799.29 Other signs and sxs. Involving emotional state• 799.51 Attention or concentration deficit (no association w/ Attention deficit disorder)• 799.55 Frontal lobe and executive function deficit• 799.59 Other signs and sxs. involving cognition• 970.89 Poisoning by other CNS stimulants• 995.2 Other and unspecified adverse effect of unspecified drug, medicinal and biologic substance (due) to correct medicinal
substance properly administered (“Adverse effects of medication, NOS”)• 995.20 Unspecified adverse effect of unspecified drug, medicinal and biologic substance
Cross Walking Diagnostic Codes: Anxiety Disorders (DSM)
• 291.89 Alcohol-induced anxiety disorder• 292 Sedative, hypnotic or anxiolytic withdrawal• 292.11 Sedative, hypnotic or anxiolytic-induced psychotic disorder, w/delusions• 292.12 Sedative, hypnotic or anxiolytic-induced psychotic disorder, w/hallucinations• 292.81 Sedative, hypnotic or anxiolytic-induced delerium• 292.83 Sedative, hypnotic or anxiolytic-induced persisting amnestic disorder• 292.84 Sedative, hypnotic or anxiolytic-induced mood disorder• 292.85 Sedative, hypnotic or anxiolytic-induced sleep disorder• 292.89 Sedative, hypnotic or anxiolytic-induced sexual dysfunction• 292.89 Caffeine-, amphetamine-, cannabis-, cocaine-induced anxiety disorder• 292.9 Sedative-,hypnotic-, anxiolytic-related disorder, NOS • 293.84 Anxiety Disorder due to (indicate general medical condition)• 300.00 Anxiety state, unspecified• 300.01 Panic disorder, w/out agoraphobia• 300.02 Generalized anxiety disorder• 300.09 Other anxiety disorder• 300.1 Dissociative, conversion and factitious disorders• 300.10 Hysteria, unspecified• 300.11 Conversion disorder• 300.12 Dissociative amnesia
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• 300.13 Dissociative fugue• 300.14 Dissociative identity disorder• 300.15 Dissociative disorder, or reaction, unspecified• 300.16 Factitious disorder w/predominately psychological signs and sxs.• 300.19 Other and unspecified factitious illness• 300.2 Phobic disorders• 300.20 Phobia, unspecified• 300.21 Agoraphobia w/panic disorder• 300.22 Agoraphobia w/out mention of panic attacks• 300.23 Social Phobia• 300.29 Other isolated or specific phobias• 300.3 Obsessive-compulsive disorders • 300.4 Dysthymic disorder• 300.5 Neurasthenia• 300.6 Depersonalization disorder• 300.7 Hypochondriasis• 300.8 Somatoform disorders• 300.81 Somatization disorder• 300.82 Undifferentiated somatoform disorder• 300.89 Other somatoform disorders• 300.9 Unspecified nonpsychotic mental disorder• 301.10 Affective personality disorder• 304.10 Sedative, hypnotic or anxiolytic dependence• 305.40 Sedative, hypnotic or anxiolytic abuse• 307.54 Vomiting, psychogenic, unspecified• 308 Acute reaction to stress• 308.0 Predominant disturbance of emotions• 308.1 Predominant disturbance of consciousness• 308.2 Predominant psychomotor disturbance• 308.3 Other acute reaction to stress• 309 Adjustment reaction• 309.21 Separation anxiety disorder• 309.22 Emancipation disorder of adolescence and early adult life• 309.23 Specific academic or work inhibition• 309.24 Adjustment disorder w/anxiety• 309.28 Adjustment disorder w/mixed anxiety and depressed mood• 309.4 Adjustment disorder w/mixed disturbance of emotions and conduct• 309.81 Post-traumatic stress disorder• 309.9 Adjustment disorder, unspecified• 309.24 Adjustment disorder w/anxiety• 309.28 Adjustment disorder w/mixed anxiety and depressed mood• 309.4 Adjustment disorder w/mixed disturbance of emotions and conduct• 309.81 Post-traumatic stress disorder• 309.9 Adjustment disorder, unspecified• 310.2 Postconcussion syndrome• 310.8 Other specified nonpsychotic mental disorders following organic brain damage• 310.9 Unspecified nonpsychotic mental disorders following organic brain damage• 313.32 Selective mutism• 313.9 Unspecified emotional disturbances of infancy, childhood or adolescence, NOS • 255.6 Medulloadrenal hyperfunction (secondary to pheochromocytoma)• 327.02 Insomnia due to a mental disorder• 424.0 Mitral valve prolapse• 780.51 Sleep disturbance, unspecified• 780.52 Insomnia, unspecified• 780.95 Excessive crying of child, adolescent or adult
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• 780.9 Other general symptoms• 780.95 Excessive crying of child, adolescent or adult• 784.0 Headache, NOS• 785.0 Tachycardia• 785.1 Palpitations• 786.05 Shortness of breath• 786.50 Chest pain, unspecified • 788.3 Urinary incontinence• 789.0 Abdominal pain• 789.05 Abdominal pain, periumbillic• 789.06 Abdominal pain, epigastric• 799.21 Nervousness• 799.22 Irritability• 799.23 Impulsiveness• 799.24 Emotional lability• 799.29 Other signs and sxs. involving emotional state• 799.51 Attention or concentration deficit (not associated with ADHD)• 799.59 Other signs and sxs. involving cognition• 995.2 Other and unspecified adverse effect of unspecified drug, medicinal and biologic substance (due) to correct medicinal
substance properly administered (“Adverse effects of medication, NOS”)• 995.20 Unspecified adverse effect of unspecified drug, medicinal and biologic substance• 970.89 Poisoning by other CNS stimulants
Cross Walking Diagnostic Codes: Depressive Disorders (DSM)
• 296 Episodic mood disorders• 296.0 Bipolar I disorder, single manic episode• 296.1 Manic disorder, recurrent episode• 296.2 Major depressive disorder, single episode• 296.3 Major depressive disorder, recurrent episode• 296.4 Bipolar I disorder, most recent episode (or current) manic• 296.5 Bipolar I disorder, most recent episode (or current) depressed• 296.6 Bipolar I disorder, most recent episode (or current) mixed• 296.7 Bipolar I disorder, most recent episode (or current) unspecified• 296.8 Other and unspecified bipolar disorder• 296.80 Bipolar disorder, unspecified• 296.81 Atypical manic disorder• 296.82 Atypical depressive disorder• 296.89 Other• 296.9 Other and unspecified episodic mood disorder• 296.99 Other specified episodic mood disorder• 298.0 Depressive type psychosis• 300.4 Dysthymic disorder• 301.12 Chronic depressive personality disorder• 301.13 Cyclothymic personality disorder• 309.0 Adjustment disorder w/ depressive mood• 309.1 Prolonged depressive reaction• 309.28 Adjustment disorder w/ mixed anxiety and depressed mood• 310.2 Postconcussion syndrome• 310.8 Other specified nonpsychotic mental disorders following organic brain damage• 310.9 Unspecified nonpsychotic mental disorders following organic brain damage• 244 Acquired hypothyroidism• 245 Thyroiditis• 280 Iron deficiency anemia• 780.7 Malaise and fatigue• 780.71 Chronic fatigue syndrome
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• 780.95 Excessive crying of child, adolescent or adult• 799.2 Signs and sxs. Involving emotional state (excludes anxiety/depression)• 799.22 Irritability• 799.24 Emotional lability• 799.25 Demoralization and apathy• 799.29 Other signs and sxs. Involving emotional state• 995.2 Adverse Effects of Medication, NOS• 995.52 Neglect of child (if focus is on victim)
Other Frequent Co-Morbid Conditions: Prenatal/Perinatal
• 760.4 Maternal nutritional disorders• 760.71 Alcohol• 760.75 Cocaine• 760.77 Anticonvulsants• 760.79 Other agents• 764.90 Intrauterine growth retardation
Other Frequent Co-Morbid Conditions: Symptoms, Signs and Ill-Defined Conditions
• 307.52 Pica• 310.1 Personality change due to (secondary to general medical condition) 307.50 Eating disorder, NOS• 327.02 Insomnia due to a mental disorder• 536.2 Cyclical vomiting• 783.0 Anorexia• 783.1 Abnormal weight gain• 783.21 Abnormal loss of weight• 783.22 Abnormal loss of weight and underweight• 783.3 Feeding problems• 783.41 Failure to thrive in childhood• 783.9 Growth/weight evaluation• 424.0 Mitral valve prolapse• 692.9 contact dermatitis• 780.51 Sleep disturbance, unspecified• 780.52 Insomnia, unspecified• 780.95 Excessive crying of child, adolescent or adult• 780.9 Other general symptoms• 780.95 Excessive crying of child, adolescent or adult• 783.0 Anorexia• 783.1 Abnormal weight gain• 783.21 Abnormal loss of weight• 783.22 Abnormal loss of weight and underweight• 783.3 Feeding problems• 783.41 Failure to thrive in childhood• 783.9 Growth/weight evaluation• 784.0 Headache, NOS• 785.0 Tachycardia• 785.1 Palpitations• 786.05 Shortness of breath• 786.50 Chest pain, unspecified • 788.3 Urinary incontinence• 789.0 Abdominal pain• 789.05 Abdominal pain, periumbillic• 789.06 Abdominal pain, epigastric• 799.21 Nervousness• 799.22 Irritability
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• 799.23 Impulsiveness• 799.24 Emotional lability• 799.29 Other signs and sxs. involving emotional state• 799.51 Attention or concentration deficit (not associated with ADHD)• 799.59 Other signs and sxs. involving cognition• 995.2 Other and unspecified adverse effect of unspecified drug, medicinal and biologic substance (due) to correct medicinal
substance properly administered (“Adverse effects of medication, NOS”)• 995.20 Unspecified adverse effect of unspecified drug, medicinal and biologic substance• 970.89 Poisoning by other CNS stimulants
Pertinent V-Codes
• V11.9 Personal hx. of unspecified mental disorder• V15.41 Personal hx. of physical abuse (including sexual abuse)• V15.42 Personal hx. of emotional abuse• V15.82 Hx. of tobacco use• V17.0 Family hx. of psychiatric condition• V40.0 Problems w/learning• V40.1 Problems w/ communication• V40.2 Other mental problems• V40.3 Mental and behavioral problems; other behavioral problems• V41.2 Problems w/hearing • V61.08 Family disruption due to extended absence of family member• V61.20 Counseling for parent/child problem, unspecified• V61.23 Counseling for parent/biological child problem• V61.24 Counseling of a parent-adoptive child problem• V61.25 counseling of a parent(guardian)-foster child problem• V61.29 Parent/child problems, other• V61.41 Alcoholism in the family• V61.42 Substance abuse in the family • V61.49 Health problems w/family; other• V61.8 Health problems w/family; other specified family circumstances (eg sibling relational problems)• V61.9 Health problems w/family; unspecified family circumstances• V62.0 Other family circumstances; unemployment• V62.3 Educational circumstances• V62.4 Social maladjustment• V62.5 Other psychosocial circumstances; legal circumstances• V62.81 Interpersonal problems, Not Elsewhere Classifiable (NEC)• V62.82 Bereavement, uncomplicated• V62.89 Other psychological or physical stress, borderline intellectual functioning, other –”phase of life problem”• V62.9 Unspecified psychosocial circumstance• V65.2 Malingering• V65.42 Counseling on substance use and abuse• V65.49 Other specified counseling• V65.5 Person w/feared complaint in whom no dx was made• V65.42 Counseling on substance use and abuse• V65.49 Other specified counseling• V65.5 Person w/feared complaint in whom no dx was made• V69.4 Lack of adequate sleep• V69.5 Behavioral insomnia of childhood• V71.02 Observation for suspected mental condition; childhood or adolescent antisocial behavior• V71.09 Other suspected mental condition• V79.1 Special screening for alcoholism• V79.2 Special screening for mental retardation• V79.3 Special screening for developmental delays in childhood• V79.9 Unspecified mental disorder and developmental handicap• V80.09 special screening for other neurological disorders
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